Background: Safety is a key component of care quality. A climate where safety is prioritized and employees feel comfortable questioning others and disclosing their own mistakes-that is, a strong safety climate-figures prominently in improving unacceptably high healthcare organization safety error rates. Nursing home staff must prioritize safety because they care for an inherently vulnerable population in which safety errors are already more likely to occur. Yet relatively little research has been done on nursing home safety climate, although studies suggest that nursing home safety climate varies considerably and that staff safety climate perceptions are related to some resident outcomes. Research also points to a possible perceived conflict for nursing home staff between safety and resident-centered care. To date, no nursing home safety climate interventions have been tested. This project builds on pilot work and incorporates feedback from VHA operations partners. It represents the first comprehensive study of Community Living Center (CLC) safety climate and the first usability study of a CLC safety climate toolkit. Objectives: The CLC Employee Survey of Attitudes about Resident Safety (CESARS) was developed to assess and help improve CLC safety climate. The CESARS consists of two parts: (1) a multi-domain CLC safety climate instrument (i.e., CESARS Survey) and (2) a CLC safety climate toolkit (i.e., CESARS Toolkit). Data from an administration of both CESARS components to employees (n=300) in 5 geographically diverse CLCs showed the CESARS Survey to be reliable and valid and the CESARS Toolkit to be well received. The current mixed-methods study builds on this work. Interim products will be shared with operations partners throughout the 3-year project period to maximize the study's impact. The study has 3 aims. (1) Identify employee and organizational characteristics associated with safety climate variation across VHA and over time. (2) Examine the relationship of safety climate to both care processes and clinical outcomes across VHA and over time. (3) Pilot the use of the CESARS Toolkit. Methods: The study will use a mixed-methods design. Aims 1 and 2 will be achieved by administering the CESARS Survey and a measure of organizational readiness to change in a random national sample of 64 CLCs at two time points (organizational readiness to change only at Time 1) and conducting quantitative analyses. Aim 3 will be achieved by conducting qualitative interviews with staff at 6 purposively sampled CLCs about safety climate and the usability of the CESARS Toolkit. These results will be used to refine the Toolkit. Quantitative and qualitative results will also be integrated to provide a comprehensive picture of safety climate nationally. Anticipated Impacts: This project will generate new knowledge about CLC safety climate. Interim study findings will be compiled into actionable reports that will be shared with operations partners at the beginnings of years 2 and 3. Final results will be disseminated with the help of these partners. The study team will also work with operations partners to disseminate the refined Toolkit. The periodic and final products will provide a nuanced picture of safety climate nationally and the relationship between safety climate and outcomes, in addition to providing detailed information on the barriers to and facilitators of using the CESARS Toolkit. These findings will help enhance care for some of VHA's most vulnerable Veterans. The knowledge gained will be of immediate applicability to CLCs nationwide and will be help guide further improvements in safety climate. Additionally, the refined CESARS Toolkit will be immediately relevant. Results will also lead directly to subsequent implementation work.